More than 10% of women experience either major or minor depression six weeks after giving birth. Postpartum depression (PPD) leads to significant biological, social, psychological, and economic consequences for the mother, the child, and the family. Clinically and cost-effective treatments are available for PPD, but less than half of PPD cases are ever diagnosed. Unfortunately, a new British Medical Journal (BMJ) report concludes that formal screening tools for PPD are not cost-effective.

The BMJ study examined a hypothetical cohort of women at six weeks postpartum and evaluated the cost-effectiveness of formal screening methods for PPD versus routine care. The screening tool used in the study, the Edinburgh postnatal depression scale (EDPS), had an incremental cost effectiveness ratio of roughly $67,000 per quality adjusted life year compared with routine care only. The authors conclude that these screening measures do not represent a good value for the money for Britain’s National Health Service (NHS). The lack of cost-effectiveness is due, in large part, to the large number of misdiagnoses and false positives that the screening tools returned.

Most formal screening strategies for PPD rely on patient self-reporting of symptoms during routine postpartum care. These tools may or may not be dependable or consistent. Still, most clinical practice guidelines recommend that primary care physicians ask a new mother simple, yet straightforward, questions about her mood and emotional well-being at her postpartum visits. What the physician does with the answers is often inconsistent, however. Mental health screening tools are imperfect and a large number of diagnosed PPD cases are false positives, adding to the controversy surrounding PPD screening. Other formal reviews of mental health evaluations and screenings in the pre- and postnatal period have delivered surprisingly weak results. Some of the studies were small and had too many interventions to separate the effectiveness of the screening tools from the treatment itself. Still, most clinicians and public health officials assert that PPD is a significant public health concern, since it can lead to health consequences for the mother and the infant long after the initial postpartum period.

Based on the results of the BMJ study, the NHS does not feel that screening strategies for PPD offer more good than harm at a reasonable cost; there is not enough clinical or cost data to recommend widespread implementation of formal screening tools. This report, of course, inspires the question associated with all such cost effectiveness analyses: how much is one year of quality life worth? Is there a dollar amount that is appropriate to apportion for a mother who is depressed after a new baby? Is any sum too much that would ensure a baby grew up with a healthy, happy mother and family?

Maybe this is just a reminder that patients cannot rely on the health care system to provide for all their health care needs. Without formal screening strategies, it is critical that a woman and her family and friends be aware of the risks for and signs of PPD. There are effective treatment strategies, if only the cases are identified.

References

Austin MP, Priest SR, & Sullivan EA (2008). Antenatal psychosocial assessment for reducing perinatal mental health morbidity. Cochrane database of systematic reviews (Online) (4) PMID: 18843682

Hewitt C, Gilbody S, Brealey S, et al. Methods to identify postnatal depression in primary care: an integrated evidence synthesis and value of information analysis. Health Technol Assess. Jul 2009;13(36):1-145, 147-230.

Hewitt, C., & Gilbody, S. (2009). Is it clinically and cost effective to screen for postnatal depression: a systematic review of controlled clinical trials and economic evidence BJOG: An International Journal of Obstetrics & Gynaecology DOI: 10.1111/j.1471-0528.2009.02148.x

Paulden, M., Palmer, S., Hewitt, C., & Gilbody, S. (2009). Screening for postnatal depression in primary care: cost effectiveness analysis BMJ, 339 (dec22 1) DOI: 10.1136/bmj.b5203